Online Reg

2023 TRAINING CAMP ENROLLMENT FORM
ATHLETE/CAMPER’S NAME:
ATHLETE’S E-MAIL ADDRESS:
PARENT'S E-MAIL ADDRESS:
BOARDING:
- Yes
- No
CAMP PROGRM:
- ELITE
- PREMIUM
2023 CAMP DATES: (check all that apply)
- April 10 - 14
- April 17 - 21
- April 24 - 28
- May 1 - 5
- May 8 - 12
- May 15 - 19
- May 22 - 26
- May 29 - June 2
- June 5 - 9
- June 12- 16
- June 19 - 23
- June 26 - 30
- July 3 - 7
- July 10 - 14
- July 17 - 21
- July 24 - 28
- July 31 - Aug 4
- Aug 7 - 11
- Aug 14 - 18
- Aug 21 - 25
PARENT or GUARDIAN INFORMATION
PARENT’S or GUARDIAN FIRST NAME:
PARENT’S or GUARDIAN LAST NAME:
PARENT/GUARDIAN COUNTRY:
- USA
- Other
PARENT’S/GUARDIAN HOME ADDRESS:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
PARENT’S/GUARDIAN PHONE INFO:
Home:
Cell:
Work:
ext.
ATHLETE’S PERSONAL INFORMATION
DOB: (mm/dd/yyyy)
Age :
GENDER :
- Male
- Female
Current School:
Current Grade:
School Coach:
School Coach Email:
Traveling Team Name:
Travel Coach Email:
SHIRT SIZE :
- SM
- MED
- LG
- XL
- XXL
EMERGENCY CONTACT INFORMATION
EMERGENCY PHONE NUMBER:
Emergency Contact Name:
Relation to Athlete:
Home Number:
Cell Number:
INSURANCE INFORMATION
Insurance Name:
Insurance Address:
Insurance Phone Number:
Insurance Fax Number:
Insured’s Name:
Insured’s DOB:
Policy #:
Group #:
SS#:
Additional Insured Info:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
RELEASE AND WAIVER OF LIABILITY

I understand that this Release and Waiver of Liability governs all rights and liabilities relating in any way to the receipt by me from Abunassar Impact Basketball, LLC and/or its agents of Services, as that term is defined below. I have read, understand, and agree to be bound by the terms below.

Definitions:

“Services” shall mean any and all manner of goods and services offered by Abunassar Impact Basketball, LLC or any other released party to you. These services, which may take the form of training, treatment, consulting, and the like, expressly include but are not limited to: evaluations; rehabilitation; reconditioning; performance planning; performance training (including strength & conditioning training, speed & quickness training, plyometric training, and the like); recovery and regeneration training; sports nutrition consultation; supplement and nutrition provision; any consultation related to any item in this list; injury reduction and treatment; technical and tactical instruction; performance enhancement

“Training” shall mean any act, omission, or other activity required of you or carried out by you in relation to the services.

“Released Parties” shall mean all Abunassar Impact Basketball, LLC staff and employees and all related governmental entities, adidas, along with, in relation to the previously listed respective Released Parties, all of their officers, directors, shareholders, insurers, partners, employees, employers, agents, successors, contractors, assigns, affiliates, parent corporations, affiliated corporations, and subsidiary corporations.

Terms & Provisions

The risk of injury from participation in sporting events and other strenuous physical activity, including Training, is significant, including the potential for permanent paralysis, other serious injury, and/or death.

I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS of participation in Training, including, without limitation, risk arising from or relating in any way to the condition of the facilities, equipment, fields, and surrounding premises, the actions of persons other than myself, my own actions, and travel to and from the Training. I UNDERSTAND THAT THE RELEASED PARTIES MAKE NO WARRANTIES and shall in no event be responsible or liable for the defective or dangerous condition of the facilities, equipment, fields, and surrounding premises, except to the extent such condition(s) result(s) solely from the gross negligence or intentional acts of a Released Party. I AGREE THAT THE RELEASED PARTIES SHALL NOT BE LIABLE for any claims, demands, injuries, damages, actions, or causes of action that arise in whole or in part due to the simple negligence of the Released Parties, or any of them.

FURTHERMORE, I FOREVER RELEASE AND DISCHARGE, AND AGREE TO INDEMNIFY AND HOLD HARMLESS, the Released Parties from and in relation to all claims, demands, injuries, damages, actions, or causes of action that arise from or relate in any way to my participation in the Training, other than such claims, demands, etc. that arise solely from the gross negligence or intentional acts of a Released Party I FURTHER WARRANT AND CERTIFY that I have no health conditions that would prevent me from participating safely in the Training, I have taken every reasonable act necessary to make this warranty and certification in relation to such participation, and that I am otherwise sufficiently fit and healthy to participate.

I WARRANT AND UNDERSTAND that it is my sole and personal responsibility to obtain insurance to compensate for any and all injuries which might arise from my participation in the Training, and furthermore agree to look solely to such insurance to cover losses resulting from any injuries, regardless of fault, and waive all rights of subrogation on behalf of any and all Released Parties which may now or ever exist as a result of such insurance.

IN ANY EVENT, THE LIABILITY OF A RELEASED PARTY TO ME FOR ANY REASON AND UPON ANY CAUSE OF ACTION SHALL NOT EXCEED THE AMOUNT ACTUALLY PAID BY ME TO ABUNASSAR IMPACT BASKETBALL, LLC DURING THE TWELVE MONTHS IMMEDIATELY PRECEDING MY ASSERTION OF SUCH CLAIM. THIS LIMITATION APPLIES TO ALL CAUSES OF ACTION IN THE AGGREGATE, INCLUDING, WITHOUT LIMITATION TO EQUITY, BREACH OF CONTRACT, BREACH OF WARRANTY, NEGLIGENCE, STRICT LIABILITY, MISREPRESENTATIONS, AND OTHER TORTS.

PHOTO/VIDEO DISCLAIMER

Abunassar Impact Basketball, LLC has my permission to use my photograph, video and audio recordings in future publications, web pages, and other promotional materials produced. I understand the circulation of the materials could be worldwide and that there will be no compensation to me for this use.

If any paragraph, subparagraph, sentence or clause of this Agreement shall be adjudged illegal, invalid or unenforceable, the balance of the Agreement shall remain in full force and effect. This agreement shall be construed and interpreted under Nevada law. Any lawsuit or claim arising from or relating in any way to Training, Services, and/or this agreement shall be brought, if at all, in Clark County, Nevada.

I have read this Agreement, fully understand its terms, understand that I have given up substantial rights by signing it, and sign it freely and voluntarily. I acknowledge that I have received valuable consideration in relation to my execution of this Agreement, which I understand to be a prerequisite to my receipt of services. Finally, I understand that this Agreement shall be of full force and effect as to any and all Services I receive from the Released Parties, without regard to the date or timing of such service.
Athlete Print Name:
Athlete Signature:
Accepted file types: jpg, png, doc, pdf, Max. file size: 256 MB.
Date:
Parent/Guardian Name:
Parent /Guardian Signature:
Accepted file types: jpg, png, doc, pdf, Max. file size: 256 MB.
Date:
INSURANCE INFORMATION

Our director of athlete recruiting will review Abunassar Impact Basketball, LLC physical therapy insurance invoicing process with you.

Physical Therapy services include, but are not limited to: • Evaluation/Re-Evaluations • Manual Therapy • Joint Mobilizations • Ultrasound • Electric Stimulation/Biofeedback • Therapeutic Exercise • Range of Motion/Flexibility • Ice/Heat • Iontophoresis/Phonophoresis • Orthotics (Athlete will be responsible for orthotic services/inserts not reimbursed by insurance company)

CONSENT TO TREAT

I understand that I may require some form of rehabilitative or preventative treatment during my stay at Abunassar Impact Basketball. I also could be referred for rehabilitative treatment to Abunassar Impact Basketball, LLC via a self-referral or referral from a physician. In such cases, an individual treatment plan will be described for me. I understand that I have the right to ask and have any questions answered prior to receiving any treatment, including any risks or alternatives to the treatment plan that has been prescribed by my physician and/or recommended by my therapist. By signing this agreement, I consent to have Abunassar Impact Basketball provide treatment and care as necessary for rehabilitation of an injury or injury prevention.

The statements are true and complete to the best of my knowledge. I understand, fully, the payment policy and billing procedures of Abunassar Impact Basketball. I hereby authorize Abunassar Impact Basketball to furnish my nsurance company(s), privately contracted medical billing provider (Platinum Medical Billing), attorney, or legal representative all information, which said parties might request concerning my present illness or injury. I hereby assign Abunassar Impact Basketball all money to which I am entitled for medical expenses related to the service reported herein, but not to exceed my indebtedness to Abunassar Impact Basketball. I certify by my signature that I have read and agree to this information.
Patient/Guardian’s Name :
Patient/Guardian’s Signature:
Accepted file types: jpg, png, doc, pdf, Max. file size: 256 MB.
Date:
ATHLETE PAST MEDICAL HISTORY FORM
Date:
Athlete’s Name:
Height: (inches)
Weight: (pounds)
1. Have you had an injury before?
- Yes
- No
please list your injuries (most recent first):
2. Check which apply to your current condition:
- Athletic injury
- Work related injury related to lifting
- Cause unknown Injury related to falling Motor vehicle accident
- Other
List of Current Condition
3. Have you had a surgery related to any of your injuries?
- Yes
- No
List surgery related injuries
4. Do you have any allergies (including medicines or supplements)?
- Yes
- No
List any allergies (including medicines or supplements)
5. Are you presently taking any medication?
- Yes
- No
please list the medication and what condition it is for:
6. Do you have, or have you had, any of the following:
Check all that apply:
CONDITION
- Diabetes
- Hypoglycemia
- Chest Pain/Angina
- Osteoarthritis
- High Blood Pressure
- Osteoporosis
- Heart Disease
- Hernia
- Heart Attack
- Seizures
- Heart Palpitations
- Metal Implants
- Pacemaker
- Dizziness/ Fainting
- Headaches
- Fractures
- Kidney Problems
- Surgeries
- Cancer
- Skin Abnormalities
- Stroke
- Nausea/ Vomiting
- Bowel/ Bladder Dysfunction
- Ringing in Your Ears
- Urine Leakage
- Rheumatoid Arthritis
- Asthma/ Breathing Problems
- Smoking
- Liver/ Gallbladder Problems
List any other conditions:
If you answered YES to any of the items above, please briefly explain and give the date. Include any other pertinent information regarding your past medical history:
CREDIT CARD INFORMATION
Camper / Athlete Name:
Each athlete is REQUIRED to have a credit card number on file. This card may be used for the following:

• Medical- In the event of emergency and medical services • Purchases- Purchases for café food, supplements, apparel, etc. • Balances Due – BALANCE DUE 30 DAYS PRIOR TO ROGRAMATTENDANCE

*Please note there will be a 3.5% service fee charge for all credit card transactions

CREDIT CARD INFORMATION
Card:
- VISA
- MASTERCARD
- AMERICAN EXPRESS
Card Number:
Expiration Date:
CVV code:
Name on Card:
Authorized Signature:
Accepted file types: jpg, png, doc, pdf, Max. file size: 256 MB.
Today’s Date:
Card Billing Address:
Card Billing City, St, Zip Code:
Card Phone Number:
*DEPOSITS ARE NON-REFUNDABLE BUT NEVER FORFEITED. IF YOUR TRAINING DATES NEED TO CHANGE YOU MAY DO SO, SUBJECT TO AVAILABILITY. WE KEEP OUR CAMP SPACES LIMITED IN ORDER TO MAINTAIN A HIGH LEVEL OF INSTRUCTION.*

2023 TRAINING CAMP ENROLLMENT FORM

PARENT or GUARDIAN INFORMATION

PARENT’S/GUARDIAN PHONE INFO:

ATHLETE’S PERSONAL INFORMATION

EMERGENCY CONTACT INFORMATION

INSURANCE INFORMATION

RELEASE AND WAIVER OF LIABILITY

Definitions:

Terms & Provisions

INSURANCE INFORMATION

CONSENT TO TREAT

ATHLETE PAST MEDICAL HISTORY FORM

CREDIT CARD INFORMATION

CREDIT CARD INFORMATION